University of Groningen
Direct observation in postgraduate training
Renting, Nienke
Published in: Medical Education DOI:
10.1111/medu.13755
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Publication date: 2018
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Renting, N. (2018). Direct observation in postgraduate training: making it happen and making it work. Medical Education, 52(12), 1218-1220. https://doi.org/10.1111/medu.13755
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Direct observation in postgraduate training: making it
happen and making it work
Nienke Renting
Successful organisation of direct observation of residents by attending physicians may make or break the implementation of competency-based approaches in postgraduate training programmes. It seems, however, that direct observation of competencies does not readily fit into most
postgraduate programmes, as it often happens infrequently and is of poor quality. Direct observation serves three important purposes in competency-based training. Firstly, direct observation is the foundation of all valid and reliable workplace-based assessment tools.1,2Secondly, feedback provided after direct observation is one of the most powerful learning tools in residency.3Finally, direct observation helps establish relationships and build mutual trust between residents and attending physicians.4Promoting assessment, feedback and
supervisory relationships are three good objectives that justify the quest for increased frequency and improved quality of direct
observation.
Promoting assessment, feedback and supervisory relationships are three good
objectives that justify the quest for increased frequency and improved
quality of direct observation
In this issue, Gauthier et al.5 investigate residents’ and attending physicians’ perceptions of direct observation before transitioning to a competency-based approach in their postgraduate internal medicine training programme. Gauthier et al.5find that many internal medicine residents and attending physicians articulated a quite narrow perspective of direct observation. Direct observation to them typically entails planned encounters when an attending physician sits in and witnesses a resident during direct patient contact, for instance when taking a history or performing a physical examination. By contrast with direct observation, when probed, some of the participants in Gauthier et al.5described
‘informal observation’ as occurring much more frequently and in an ad hoc manner. Informal observation entails, for instance, handovers, managing cases and interactions with other health care professionals. Basically, almost any professional situation that occurs during day-to-day collaboration of attending physicians and residents, on the ward and in the outpatient clinic, might be suitable for direct observation if framed more broadly, by including what the participants mentioned as ‘informal observation’. By
reframing direct observation more broadly, suddenly
competency-based postgraduate training becomes a lot less time consuming and a lot more feasible.
By reframing direct observation more broadly, suddenly competency-based postgraduate training becomes a lot less time consuming and a lot more feasible
I warmly embrace the advice of Gauthier et al.5to reframe ‘direct observation’ much more broadly and to incorporate also
professional situations outside of patient encounters. In fact, that is exactly what we did when we transitioned our postgraduate internal medicine programme to a competency-based approach. We developed a feedback system that included direct observation of residents in a variety of professional situations to provide them with immediate and specific feedback.6 Five authentic professional situations were determined to together cover all CanMEDS roles. Structuring observation and formative feedback in this way helped to transition towards competency-based training. The system helped attending physicians to provide high-quality specific feedback on the defined CanMEDS roles. Furthermore, it ensured attention beyond medical
expertise, including roles that had not been part of medical training for a long time. This was a very important finding, given that many programmes still struggle to sufficiently incorporate considered ‘difficult’, CanMEDS roles such as collaborator or leader that cannot directly be observed during patient encounters.
1218 ª 2018 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd; MEDICAL EDUCATION 2018 52: 1216–1222
Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands Correspondence: Nienke Renting, Department of Innovation Management and Strategy, Faculty of Economics and Business, University of Groningen, Nettelbosje 2, 9747 AE Groningen, the Netherlands. Tel: 00 31 50 363 7438; 31 50 363 2884; E-mail: n.renting@rug.nl
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. doi: 10.1111/medu.13755
So how can we stimulate more and better direct observation in our training programmes? Direct observation should be approached systematically and achieved with careful consideration of
organisational culture and values, in order to be able to tackle inevitable obstructions.7 The participants in Gauthier et al.5, described reduced efficiency as an important hindrance to the implementation of (more) direct observation. Furthermore, both residents and attending physicians seem to have their reasons for refraining from initiating direct observation. Residents have a significant amount of anxiety during direct observation, a fear of possible consequences if deficiencies are uncovered and a fear of bothering busy attending physicians too much.5,8
Simultaneously, attending
physicians also hesitate to initiate direct observation because they are afraid residents might feel mistrusted and worry that their autonomy will be jeopardised.4 Therefore, a system with a solid foundation of planned direct observations and added tailored direct observations, where
needed, seems the only way to go about it. Regularly planned observations become part of ‘business as usual’ and make direct observation less scary. Additional tailored observations should be mutually agreed on by residents and attendings
physicians, and optimally support learning by connecting to
residents’ individual learning needs.
Therefore, a system with a solid foundation of planned direct observations and added tailored direct,
observations, where needed, seems the only way to go about it
Although direct observation has great learning potential, learning does not occur simply because an attending physician observes an activity. So how can we make sure direct observation realises its full learning potential instead of being just a waste of valuable time? It may very well be that the term ‘direct observation’ still brings an image to mind of what anthropologists have been doing for over a century: essentially becoming a
metaphorical ‘fly on the wall’ by quietly observing and affecting the situation as little as possible. An attending physician can never become this unnoticed fly and is, fortunately, much more valuable for residents’ learning when taking on an active role. Direct
observation can be bidirectional, where the resident and attending physician naturally take turns in acting and observing during patient encounters based on the residents’ abilities.4Attending physicians can ask probing questions during case presentations to disclose residents’ clinical reasoning.5Attending physicians can provide residents with constructive and specific feedback afterwards, to boost residents’ learning.6Moreover, direct observation contributes to quality of care, functioning as a safety net, as attending physicians can step in whenever needed.5
So how can we make sure direct observation realises its full learning potential instead of being just a waste of
valuable time?
I imagine many of the attending physicians in the study by Gauthier et al.5and elsewhere, would say that a lot of the above is already occurring in their daily practice. Great! The transition towards a competency-based approach does not have to be disruptive. So why
adopt a competency-based approach? Because competency frameworks may help to better respond to the changing environment of
postgraduate training. Workplace-based learning increasingly affords fragmented, brief contact of residents with multiple attending physicians, who must attempt to quickly assess the residents’ learning needs and professional abilities.9Only systematic direct observation can help make these assessments and aid progressively increased autonomy and trust throughout residency. It also has the potential to aid supervisory handovers from one attending physician to the next, something that happens rarely and causes discontinuity in residents’ learning.10Competency
frameworks ideally provide focus during direct observation and become part of a shared language to talk about learning trajectories and performance.
Competency frameworks ideally provide focus during direct observation and become part of a shared language to talk
about learning trajectories and performance
REFERENCES
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2 Ahmed K, Miskovic D, Darzi A, Athanasiou T, Hanna GB. Observational tools for assessment of procedural skills: a systematic review. Am J Surg 2011;202 (4):469–80.
3 Norcini J, Burch V. Workplace-based assessment as an
1219 ª 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education;
MEDICAL EDUCATION 2018 52: 1216–1222
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4 Rietmeijer CBT, Huisman D, Blankenstein AH, de Vries H, Scheele F, Kramer AWM, Teunissen PW. Patterns of direct observation and their impact during residency: general practice supervisors’ views. Med Educ 2018;52 (9):981–91.
5 Gauthier S, Melvin L, Mylopoulos M, Abdullah N. Resident and attending physician perceptions of direct observation in internal medicine: a qualitative study. Med Educ 2018;52 (12):1249–58.
6 Renting N, Gans ROB, Borleffs JCC, van der Wal MA, Jaarsma ADC, Cohen-Schotanus J. A feedback system in residency to evaluate CanMEDS roles and provide high-quality feedback: exploring its application. Med Teach 2016;38 (7):738–45. 7 Watling C, LaDonna KA, Lingard
L, Voyer S, Hatala R. ‘Sometimes the work just needs to be done’: socio-cultural influences on direct observation in medical training. Med Educ 2016;50 (10):1054–64. 8 LaDonna K, Hatala R, Lingard L,
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10 Renting N, Raat ANJ, Dornan T, Wenger-Trayner E, van der Wal MA, Borleffs JCC, Gans ROB, Jaarsma ADC. Integrated and implicit: how residents learn CanMEDS roles by participating in practice. Med Educ 2017;51 (9):942–52.
Thinking in new and deeper ways about clinical
reasoning
Edward Krupat
During my doctoral studies, a master teacher who greatly influenced my approach to
research told me that the very best research studies had two special qualities. First, they asked interesting and important questions that others had not yet addressed, filling gaps in the literature and extending our horizons. Second, although these studies provided useful answers, they ended up asking more questions than they answered. According to these two criteria, the paper by ALQahtani et al.1in this issue is a first rate one. However, another criterion by
which I was taught to assess studies was whether the research delivers on what was promised, and on that count I was left wanting more after reading this paper.
As to the criterion of asking important questions, this study asks us to think in depth about clinical reasoning. Rather than go the standard route of
manipulating an independent variable (in this case, time pressure) and determining its ability to affect a dependent variable/outcome (in this case, accuracy), it asks us to delve deeper. By design, it allows and encourages us to think about what is in the black box; about why the predictor variable is related to the outcome. Although simply seeking to identify associations between predictor and outcome is honourable and time tested, too much of the literature in medical education and clinical reasoning, some of my own included, typically
stops short of taking that next step. Instead, this study plunges us into the consideration of
mediators and moderators, pressing us to identify the mechanisms that account for the relationship between time pressure and accuracy. When health
professionals are rushed, it asks, does their accuracy take a hit via stress-related mechanisms, or is the culprit primarily cognitive (e.g. the reduced consideration of alternatives). By posing second-order questions, this study seeks to provide some preliminary answers to the questions behind the time– accuracy connection, and in doing so invites us to ask new questions about other variables that interact with and mediate key outcomes. Does time pressure simply narrow clinicians’ perspectives and their differential, or does stress distract them from absorbing information efficiently? Do the relevant mechanisms act similarly when clinicians are experienced or
Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
Correspondence: Edward Krupat, Beth Israel Deaconess Medical Center, Boston, Center for Education, 330 Brookline Ave, Boston, Massachusetts, USA.
E-mail: edkrupat@gmail.com doi: 10.1111/medu.13751
1220 ª 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education; MEDICAL EDUCATION 2018 52: 1216–1222
